Pancreatic Cancer

Pancreatic cancer is an abnormal growth of the cells of the pancreatic duct, the tube that drains the juices made by the pancreas to aid digestion in the small intestine. The pancreas also makes hormones, such as insulin and glucagon. The hormones go directly into the bloodstream to help the body use and store the energy it gets from food. The pancreas is located behind the stomach.
According to the American Cancer Society , in 2012 in the United States:

  • Approximately 43,920 people (22,090 men and 21,830 women) will be diagnosed with pancreatic cancer.
  • Approximately 37,390 people (18,850 men and 18,540 women) will die of pancreatic cancer

Multidisciplinary Cancer Clinic

We always follow a team approach to care. Patients have their diagnosis discussed by oncologists, surgeons, gastroenterologists, radiation oncologists and pathologists. By having everyone involved, a personalized treatment plan is developed.

Diagnosing Pancreatic Cancer: Diagnostic Tests and Stages of Disease

Patients with symptoms suspicious for pancreatic cancer will have tests to determine the cause of these symptoms.

These may include:

  • A CT scan which is performed using special protocols to ensure that very small tumors can be detected and that spread of the cancer to other organs is not detected.
  • Endoscopic ultrasound, used to diagnose small tumors that cannot be detected by a CT scan or MRI
  • A definite tissue diagnosis of pancreatic cancer, which then allows radiation and/or chemotherapy to proceed. This is performed by endoscopic ultrasound with fine needle aspiration. The endoscopic ultrasound provides image guidance for placing a fine needle to extract cells for evaluation, also known as a biopsy.

Pancreatic cancer can be classified (or staged) into three main groups:

  • Operable cancer, which means a tumor is able to be surgically removed primarily, or following chemotherapy with or without radiation therapy (resectable or borderline resectable). Borderline resectable tumors are those tumors which are touching important structures that may be able to be removed and reconstructed if necessary. These tumors are often treated with chemotherapy with or without radiation prior to surgery to try to shrink the tumor away from these important structures.
  • Locally advanced cancer, which means the tumor is found only in the pancreas with no evidence of spread to other organs, but is involving structures which cannot be safely removed (tumors at this stage are unresectable).
  • Metastatic disease, which means that the cancer has spread to other parts of the body, for example, the liver (tumors at this stage are also unresectable).

These classification groups help to determine the most effective way to treat the cancer. If it’s determined that the cancer can be successfully removed, then surgery is considered.
For patients with localized, but not operable, cancer, two treatment strategies are used:

  • A combination of chemotherapy and radiation
  • Chemotherapy alone
  • Clinical trials which include promising therapies for pancreatic cancer, which are compared to existing treatments for pancreatic cancer

Pancreatic Cancer Treatment

Treatment for pancreatic cancer begins with a personalized plan developed by pancreatic oncologists, surgeons, pathologists and other medical experts at our Tumor Board. For most patients, the plan uses multiple kinds of treatments, or therapies, in order to control the disease and improve outcomes. The sequence of therapies – chemotherapy, radiation therapy and surgery – is tailored to patients individually and depends on the tumor’s location and the extent of disease. Overall health status and quality of life are also factored heavily into the decisions for treatment and recommended therapies.

Surgery for Pancreatic Cancer

When patients are diagnosed with pancreatic cancer, approximately 20% of the tumors are found to be operable or resectable. The location of the pancreas adds to the technical difficulties of a surgical operation.

Diagnostic tests give information about the size, location and involvement of other surrounding tissues and vessels. These tests help the surgeon determine whether a cancer is operable or resectable. In addition, a surgeon will evaluate the patient’s overall health to determine if the patient can tolerate the surgical procedure. Each case is individual. In some cases, chemotherapy and radiation therapy, or other new agents, given as part of a clinical trial, will be recommended to potentially reduce the size of the tumor and improve the outcome of surgery. If the tumor is found to be in the head of the pancreas and is operable, the surgical procedure performed is a pancreaticoduodenectomy, also called a Whipple procedure. This surgery involves removing the head of the pancreas, the gallbladder, part of the bile duct, and part of the stomach. Surgery includes re-connecting the remainder of the bile duct, pancreas and stomach to the bowel so these structures can drain properly.

When does a patient see a gastroenterologist?

Gastroenterologists provide complex diagnostic services and treatment for complications related to pancreatic cancer:
Jaundice is the most common complication of pancreatic cancer that is treated by gastroenterology experts. When a mass or cancer blocks the bile duct, there is a buildup of fluid causing jaundice, which is evident by a yellow appearance of the skin. To treat jaundice, a stent is placed in the bile duct to allow the bile to drain into the intestine again as it did prior to the blockage by the tumor. Occasionally, due to changes in a patient’s anatomy such as prior obesity surgery or a blockage that cannot be traversed using an endoscope, the patient will require placement of a biliary stent through the abdominal wall or skin (percutaneously). This will occur in the Radiology department and is called a ‘PTC’, or percutaneous transhepatic cholangiocatheter. In this case the bile may sometimes drain into a bag on the outside of the body rather than internally.
In the case of family history of pancreatic cancer, or a genetic disorder that predisposes people to pancreatic cancer, there are also surveillance examinations. Gastroenterologists use endoscopic ultrasound (EUS) for this exam, which involves using an endoscope, which is a lighted, flexible tube, about the thickness of a finger, to examine the pancreas and to create detailed pictures using ultrasound imaging. EUS is the most sensitive test for picking up small cancers.

Radiation Therapy For Pancreatic Cancer

Radiation therapy is used in three ways:

  • To decrease the risk of local recurrence after surgery
  • To reduce the size of the tumor before surgery (preoperative or neoadjuvant therapy) and
  • As part of a treatment regimen for patients who have a tumor that is found to be unresectable.

When radiation is used, it is often in combination with chemotherapy, or with other new treatments as part of a clinical trial, which enhances the effectiveness of the radiation. Radiation and chemotherapy together have been found to benefit patients with locally advanced pancreatic cancer.

Chemotherapy For Pancreatic Cancer

The goals of chemotherapy treatment are to control the cancer, keep it from spreading by slowing the cancer’s growth and improve or reduce the symptoms of the disease. Chemotherapy is often used for cancer that is found to be locally advanced or metastatic (spread to other organs). These drugs can have an effect on the cancer by stopping the growth of cancer cells or their ability to multiply.

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